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PsychopharmacologyPsychopharmacology

Khalid Bazaid, MB BS, FRCPCKhalid Bazaid, MB BS, FRCPCAssistant ProfessorAssistant Professor

Child & Adolescent PsychiatristChild & Adolescent PsychiatristDepartment of PsychiatryDepartment of Psychiatry

College of MedicineCollege of MedicineKing Saud UniversityKing Saud University

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OutlinesOutlines

The role of psychotropic in the mental health and its The role of psychotropic in the mental health and its therapeutic indicationstherapeutic indications

Identify specific cautions to be aware of the various Identify specific cautions to be aware of the various psychotropic medicationspsychotropic medications

Discuss the adherence to medication treatmentDiscuss the adherence to medication treatment

Psychotropic Medications ClassificationsPsychotropic Medications Classifications

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The aim is learn how to choose a psychotropic drug that is more:

• Effective• Less toxic• Better-tolerated• The most targeted therapeutic agents

PsychopharmacologyPsychopharmacology

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Psychotropic DrugsPsychotropic Drugs Focus of all mental activity is the CNS (brain)Focus of all mental activity is the CNS (brain)

Origin of psychiatric illness caused by many factors:Origin of psychiatric illness caused by many factors:– GeneticsGenetics– Neurodevelopment factorsNeurodevelopment factors– Endocrinologic e.g. HypothyroidismEndocrinologic e.g. Hypothyroidism– Autoimmune system (infections)Autoimmune system (infections)– DrugsDrugs– Psychosocial experiences, stressors … etc.Psychosocial experiences, stressors … etc.

To date …Theories behind use of psychotropic drugs To date …Theories behind use of psychotropic drugs focuses on neurotransmitters and their receptorsfocuses on neurotransmitters and their receptors

Psychotropic drugs act by modulating neurotransmittersPsychotropic drugs act by modulating neurotransmitters

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Use of psychotropic medicationsUse of psychotropic medications

Relieve or reduce symptoms/signs of dysfunctional Relieve or reduce symptoms/signs of dysfunctional thoughts, moods, or actions of mental illnessthoughts, moods, or actions of mental illness

Improve client’s functioningImprove client’s functioning

Increase compliance to other therapiesIncrease compliance to other therapies

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Therapeutic Effects of Therapeutic Effects of Psychotropic MedicationsPsychotropic Medications

Do not “cure”Do not “cure” Relieve or decrease Relieve or decrease

symptomssymptoms Prevent or delay return Prevent or delay return

of S/Sof S/S Cannot be used as the Cannot be used as the

sole treatment for sole treatment for disordersdisorders

Need informed consent Need informed consent before startingbefore starting

Are broad spectrum and Are broad spectrum and have effects on a large have effects on a large number of S/Snumber of S/S

Initial effects are Initial effects are sedative in naturesedative in nature

May take weeks for May take weeks for effects to be seeneffects to be seen

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Reasons for Non- adherence:Reasons for Non- adherence:

Medications are Medications are expensiveexpensive

Unpleasant side effectsUnpleasant side effects

Feel better and decide Feel better and decide no longer needno longer need

Stigma associated with Stigma associated with having a mental illness having a mental illness and taking medicationsand taking medications

Paranoia or fears about Paranoia or fears about medication usage medication usage particularly additionparticularly addition

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Encouraging Compliance to Encouraging Compliance to Medication RegimenMedication Regimen

Follow-up appointments With client to verify that client Follow-up appointments With client to verify that client understands:understands:

the purpose, proper administration, intended effects, side and the purpose, proper administration, intended effects, side and toxic effects of, and how to treat problems associated with toxic effects of, and how to treat problems associated with medicationsmedications

Appropriate lab tests must be conducted to prevent Appropriate lab tests must be conducted to prevent complications and assure correct levels of drugscomplications and assure correct levels of drugs

Encourage clients to participate in medication groupsEncourage clients to participate in medication groups

Can use injections of antipsychotics which will last Can use injections of antipsychotics which will last from 2-4 weeks if clients are non-compliantfrom 2-4 weeks if clients are non-compliant

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Efficacy of Psychotropics with Efficacy of Psychotropics with Children & ElderlyChildren & Elderly

Use with great caution Use with great caution

Start Start low and go slowlow and go slow for both elders and for both elders and childrenchildren

Children are faster metabolizer whereas elders Children are faster metabolizer whereas elders have decrease liver & renal functionhave decrease liver & renal function

Risk of injuries and falls with elderlyRisk of injuries and falls with elderly

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Client & Family TeachingClient & Family Teaching

Purpose of the meds Purpose of the meds and benefits, side and benefits, side effects and how to effects and how to treat SEtreat SE

What S/S indicate a What S/S indicate a toxic effect, and how toxic effect, and how to treat, and whom to to treat, and whom to call.call.

Specific instructions Specific instructions about how to take the about how to take the medicationsmedications

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Psychotropic Medications Psychotropic Medications ClassificationsClassifications

Antipsychotics Antipsychotics (Neuroleptics)(Neuroleptics)

Mood StabilizersMood Stabilizers

AntidepressantsAntidepressants

Anxiolytics Anxiolytics (antianxiety)(antianxiety)

SedativesSedatives

HypnoticsHypnotics

PsychostimulantsPsychostimulants

Antihistamines, Antihistamines, antimuscarinics, antimuscarinics, dopamine agonistsdopamine agonists

Psychotropic Medications Psychotropic Medications Classifications … Classifications … continuedcontinued

In many instances, drugs have multiple indications:

• SSRIs (selective serotonin reuptake inhibitors) are both antidepressants and anxiolytics.

• SDAs (serotonin-dopamine antagonists) are both antipsychotics and mood stabilizers.

• Psychotropic drugs have also been organized according to structure (e.g. Tricyclic).

• mechanism (e.g. monoamine oxidase inhibitor [MAOI])

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AntipsychoticsAntipsychotics

Schizophrenia Schizophrenia DisordersDisorders

Bipolar disorderBipolar disorder

Major Depression with Major Depression with psychotic featurespsychotic features

Tourette’s SyndromeTourette’s Syndrome

Delirium, Dementia, Delirium, Dementia, and Delusions and Delusions

Control of intractable Control of intractable hiccupshiccups

Aggressive behaviorAggressive behavior

Antipsychotic - NeurolepticsAntipsychotic - Neuroleptics First generationFirst generation Post synaptic D2 receptor.Post synaptic D2 receptor. Dopamine receptor antagonists Dopamine receptor antagonists

(DRAs)(DRAs)

Low potency: Low potency: hypotension, sedation, weight gainhypotension, sedation, weight gain more anticholinergicmore anticholinergic less antidopamenergic less antidopamenergic less EPS.less EPS.

e.g.e.g. Mellaril, chlorpromazineMellaril, chlorpromazine

High potency:High potency: More antidopamenergicMore antidopamenergic more EPSmore EPS less anticholinergic less anticholinergic

e.g. e.g. HaldolHaldol

Atypical AntipsychoticsAtypical Antipsychotics ((22ndnd and 3 and 3rd rd generation)generation)

D2, D4, 5HT2 D2, D4, 5HT2 Serotonin dopamine antagonists Serotonin dopamine antagonists

(SDAs)(SDAs) Alpha adrenergic, muscarinic Alpha adrenergic, muscarinic

receptorsreceptors

e.g.e.g. ClozarilClozaril RisperdalRisperdal ZyprexaZyprexa

SeroquelSeroquel Abilify Abilify GeodonGeodon InvegaInvega ZeldoxZeldox

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First Generation Antipsychotic First Generation Antipsychotic Block predominantly Block predominantly

dopamine activitydopamine activity– High incidence of abnormal High incidence of abnormal

movementsmovements

– little effect on serotoninlittle effect on serotonin

(Also blocks acetylcholine, (Also blocks acetylcholine, norepinephrine to some norepinephrine to some degree)degree)

Blocks the H receptor Blocks the H receptor for histaminefor histamine– results in sedation and results in sedation and

weight gainweight gain

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Side Effects of 1Side Effects of 1stst Gen Drugs-1 Gen Drugs-1 DystoniaDystonia (EPS) (EPS)

spasms of the eye, neck-spasms of the eye, neck-torticollis, back, tongue-torticollis, back, tongue-happens within 72 hrs happens within 72 hrs ( ( reversible)reversible)

Akathisia Akathisia (EPS)(EPS)

restlessness restlessness

Pseudoparkinson Pseudoparkinson - S/S - S/S similar to Parkinson's-see similar to Parkinson's-see in 1-2 weeks. May in 1-2 weeks. May disappear. TX. With disappear. TX. With CogentinCogentin

Tardive DyskinesiaTardive Dyskinesia--bizarre facial and tongue bizarre facial and tongue movements (movements (irreversible)irreversible)

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Side Effects of 1Side Effects of 1stst Gen Drugs-2 Gen Drugs-2

Blurred vision, dry mouth, Blurred vision, dry mouth, constipation and urinary constipation and urinary retention, tachycardia-retention, tachycardia-anticholinergic S/Eanticholinergic S/E

Sexual dysfunctionSexual dysfunction

Severe dysrhythmiasSevere dysrhythmias

Orthostatic hypotensionOrthostatic hypotension

AgranulocytosisAgranulocytosis

In men can lead to In men can lead to gynecomastiagynecomastia

AmenorrheaAmenorrhea

GalactorrheaGalactorrhea

photosensitivity & skin rashes photosensitivity & skin rashes

Reduction is seizure threshold Reduction is seizure threshold – Low potency – Low potency

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Precautions and/or contraindicated Precautions and/or contraindicated When using 1When using 1stst Gen Antipsychotics Gen Antipsychotics

Blood dyscrasiasBlood dyscrasias

Liver, renal, or cardiac insufficiencyLiver, renal, or cardiac insufficiency

CNS depressants, including ETOHCNS depressants, including ETOH

Tegretol in conjunction with Tegretol in conjunction with antipsychotics causes up to 50% antipsychotics causes up to 50% reduction in antipsychotic reduction in antipsychotic concentrationsconcentrations

SSRI’s in conjunction with SSRI’s in conjunction with antipsychotics may cause sudden antipsychotics may cause sudden onset of EPSonset of EPS

Don’t give if have: Parkinson's Don’t give if have: Parkinson's disease, prolactin dependent cancer disease, prolactin dependent cancer of the breastof the breast

Cigarette smoking causes reduced Cigarette smoking causes reduced plasma concentrations of plasma concentrations of antipsychoticsantipsychotics

Antacids, activated charcoal can Antacids, activated charcoal can reduce the absorption of DRAsreduce the absorption of DRAs

Faverin in conjunction with Faverin in conjunction with antipsychotics causes increased antipsychotics causes increased concentrations of Haldol and Clozarilconcentrations of Haldol and Clozaril

Beta Blockers in conjunction with Beta Blockers in conjunction with antipsychotics cause severe antipsychotics cause severe hypotensionhypotension

Antidepressants in conjunction with Antidepressants in conjunction with antipsychotics may cause increased antipsychotics may cause increased plasma level of bothplasma level of both

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First Generation Antipsychotic First Generation Antipsychotic MedicationsMedications

Are useful in getting out of control behavior under Are useful in getting out of control behavior under control quickly. control quickly.

These can be given with lithium to get treat acute These can be given with lithium to get treat acute mania.mania.

Seroquel is effective in the maintenance treatment of Seroquel is effective in the maintenance treatment of Bipolar-Depressive phaseBipolar-Depressive phase

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Atypical AntipsychoticsAtypical Antipsychotics Action: Blocks dopamine receptors and to a lesser degree Action: Blocks dopamine receptors and to a lesser degree

serotonin receptors, serotonin receptors, Also block receptors for norepinephrine , histamine, Also block receptors for norepinephrine , histamine,

acetylcholineacetylcholine

Nicer drugs and are used more Nicer drugs and are used more

Decrease positive and negative S/S of SchizophreniaDecrease positive and negative S/S of Schizophrenia

Lower Incidence of abnormal movementsLower Incidence of abnormal movements

Biggest S/E is weight gain e.g. ZyprexaBiggest S/E is weight gain e.g. Zyprexa

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Positive & Negative S/S of Positive & Negative S/S of SchizophreniaSchizophrenia

Positive:Positive:– HallucinationsHallucinations– DelusionsDelusions– Abnormal thoughtsAbnormal thoughts– Bizarre behaviorBizarre behavior– Confused thoughtsConfused thoughts

Negative:Negative:– Blunted affectBlunted affect– Poverty of speechPoverty of speech– Social withdrawalSocial withdrawal– Poor motivationPoor motivation

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Atypical Antipsychotics-2Atypical Antipsychotics-2ndnd & 3 & 3rdrd generation: Clozaril (clozapine)generation: Clozaril (clozapine)

low incidence of abnormal movementslow incidence of abnormal movements

Most common S/E: Most common S/E: – Nausea, constipation, sedation, drowsiness, weight gainNausea, constipation, sedation, drowsiness, weight gain

Other S/E are:Other S/E are:– hypersalivation, tachycardia, dizziness, seizure riskhypersalivation, tachycardia, dizziness, seizure risk

possible fatal side effect:possible fatal side effect:– bone marrow suppression & Agranulocytosis (rare)bone marrow suppression & Agranulocytosis (rare)

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Atypical Antipsychotics-2Atypical Antipsychotics-2ndnd & 3 & 3rdrd generation - 2generation - 2

RisperidoneRisperidone– Does not cause bone Does not cause bone

marrow suppressionmarrow suppression– Can cause at higher Can cause at higher

doses movement doses movement disordersdisorders

– Available as a long Available as a long acting injectionacting injection

– Can be used to treat Can be used to treat maniamania

SeroquelSeroquel (Quetiapine) (Quetiapine)– S/E sedation, weight S/E sedation, weight

gain and headache gain and headache – Not associated with Not associated with

abnormal movementsabnormal movements– May cause AV blockMay cause AV block

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Atypical Antipsychotics-2Atypical Antipsychotics-2ndnd & 3 & 3rdrd generation - 3generation - 3

Zyprexa Zyprexa (Olanzapine)(Olanzapine)– does not cause bone marrow suppressiondoes not cause bone marrow suppression– Can cause weight gain & hyperglycemiaCan cause weight gain & hyperglycemia– Drowsiness, dry mouth, constipation, and restlessnessDrowsiness, dry mouth, constipation, and restlessness

Geodon Geodon (Ziprasidone)(Ziprasidone)– Binds to multiple receptor sitesBinds to multiple receptor sites– Drowsiness, headache, GI upsetDrowsiness, headache, GI upset– Can prolong the QT interval-can be fatal if history of cardiac arrhythmiasCan prolong the QT interval-can be fatal if history of cardiac arrhythmias

AbilifyAbilify (Aripiprazole) (Aripiprazole)– Dopamine stabilizerDopamine stabilizer– Partial agonist at the D2 receptorPartial agonist at the D2 receptor– In areas of the brain with excess dopamine, it lowers dopamineIn areas of the brain with excess dopamine, it lowers dopamine– In areas of low dopamine, it stimulates receptors to raise the dopamine levelIn areas of low dopamine, it stimulates receptors to raise the dopamine level– Main S/E are headache, somnolence, agitation, anxiety, insomnia, and GI Main S/E are headache, somnolence, agitation, anxiety, insomnia, and GI

upsetupset

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Antipsychotics-Long acting Antipsychotics-Long acting preparationpreparation

Can be given be given as an IM injection Can be given be given as an IM injection (depot preparations) if have difficulty (depot preparations) if have difficulty taking oral meds.taking oral meds.

Can use lower doses when given IM, so Can use lower doses when given IM, so less risk of tardive dyskinesialess risk of tardive dyskinesia

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Neuroleptic Malignant SyndromeNeuroleptic Malignant Syndrome

Rare, but fatal complication from all antipsychotic drugsRare, but fatal complication from all antipsychotic drugs

See more with 1See more with 1stst generation drugs generation drugs

Severe muscle rigiditySevere muscle rigidity

High temperatureHigh temperature

Associated S/S:Associated S/S:

TachycardiaTachycardia

HypertensionHypertension

StuporStupor

ComaComa

Abnormal labs including leukocytosis , Elevated Creatinine phosphokinase (CPK) & Abnormal labs including leukocytosis , Elevated Creatinine phosphokinase (CPK) & LFTLFT

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Mood StabilizersMood Stabilizers

Used in the treatment of Manic (Bipolar) Used in the treatment of Manic (Bipolar) disorder, and in some forms of depressiondisorder, and in some forms of depression

Drugs used: Lithium and Antiepileptic DrugsDrugs used: Lithium and Antiepileptic Drugs

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LithiumLithium

Mechanism of action Mechanism of action unknownunknown

Alters electrical Alters electrical conductivityconductivity – potential threat to all potential threat to all

body functions that body functions that are regulated by are regulated by electrical currentselectrical currents

Can cause polyuria and Can cause polyuria and polydipsa due to Na and polydipsa due to Na and K alterationsK alterations

Has the lowest Has the lowest therapeutic index of all therapeutic index of all psych drugspsych drugs

Have to monitor blood Have to monitor blood levels levels

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LithiumLithium Maintenance blood levels of Maintenance blood levels of

lithium are usually 0.4-1.3 mEq lithium are usually 0.4-1.3 mEq (toxicity occurs with levels > (toxicity occurs with levels > 1.5 mEq/L)1.5 mEq/L)

Sign of toxicity is a fine Sign of toxicity is a fine intention tremor that becomes intention tremor that becomes more pronounced and coarsemore pronounced and coarse

Risk of thyroid & kidney Risk of thyroid & kidney diseasedisease

If toxic S/S occur discontinue If toxic S/S occur discontinue the drug and notify health care the drug and notify health care providerprovider

Lithium should be taken with Lithium should be taken with foodfood

Client must eat a balanced diet Client must eat a balanced diet with normal sodium intake and with normal sodium intake and take in adequate fluid (about 2-3 take in adequate fluid (about 2-3 liters/day). liters/day).

Excretion is via renal system Excretion is via renal system

Dehydration and salt restriction Dehydration and salt restriction can increase lithium levels & can increase lithium levels & cause toxicity.cause toxicity.

Takes 2-3 weeks for lithium to Takes 2-3 weeks for lithium to become effective (may use become effective (may use antipsychotic until therapeutic antipsychotic until therapeutic levels are reached)levels are reached)

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Signs & Symptoms of Lithium Signs & Symptoms of Lithium ToxicityToxicity

Fine hand tremors that Fine hand tremors that progress into coarse progress into coarse tremorstremors

Mild GI upset Mild GI upset progressing to progressing to persistent upsetpersistent upset

Slurred speech and Slurred speech and muscle weakness muscle weakness progressing to mental progressing to mental confusionconfusion

Severe ToxicitySevere Toxicity: : – decrease level of decrease level of

consciousness to consciousness to stupor and finally stupor and finally comacoma

– Seizures, severe Seizures, severe hypotension, severe hypotension, severe polyuria with dilute polyuria with dilute urineurine

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LithiumLithium

Lithium serum concentrations are increased by Lithium serum concentrations are increased by Flouxetine (Prozac), ACE inhibitors, Thiazide diuretics, Flouxetine (Prozac), ACE inhibitors, Thiazide diuretics, and NSAIDsand NSAIDs

Lithium serum concentrations are decreased by Lithium serum concentrations are decreased by theophylline, osmotic diuretics, and urine alkalinizerstheophylline, osmotic diuretics, and urine alkalinizers

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Contraindications for LithiumContraindications for Lithium Renal diseaseRenal disease

Cardiac diseaseCardiac disease

Severe dehydrationSevere dehydration

Sodium depletionSodium depletion

Brain damageBrain damage

Pregnancy or lactationPregnancy or lactation

Use with caution in the elderly or clients with diabetics, thyroid Use with caution in the elderly or clients with diabetics, thyroid disorders, urinary retention, and seizuresdisorders, urinary retention, and seizures

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Anticonvulsants/Antiepileptic Anticonvulsants/Antiepileptic DrugsDrugs

Causes an increase in GABA in the CNS-which causes Causes an increase in GABA in the CNS-which causes a decrease in anxiety.a decrease in anxiety.

Reduce the mood swings with bipolar Reduce the mood swings with bipolar

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Anticonvulsants/Antiepileptic Anticonvulsants/Antiepileptic DrugsDrugs

Tegretol Tegretol (carbamazepine)-also used to treat (carbamazepine)-also used to treat severe pain (i.e. trigeminal neuralgia), cause severe pain (i.e. trigeminal neuralgia), cause agranulocytosis and aplastic anemiaagranulocytosis and aplastic anemia

DepakoteDepakote (Valproic acid)-can cause hepatic (Valproic acid)-can cause hepatic failure, pancreatitis, & thrombocytopenia. failure, pancreatitis, & thrombocytopenia. Watch Watch for liver failurfor liver failuree

KlonopinKlonopin (Clonazepam)(Clonazepam)

LamictalLamictal (Lamotrigine)-can have a rare but fatal (Lamotrigine)-can have a rare but fatal dermatological conditiondermatological condition

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Toxic Effects of AnticonvulsantsToxic Effects of Anticonvulsants

Tegretol can cause agranulocytosis and Tegretol can cause agranulocytosis and aplastic anemiaaplastic anemia

Depakote can cause liver dysfunction, hepatic Depakote can cause liver dysfunction, hepatic failure, and blood dyscrasias including failure, and blood dyscrasias including thrombocytopenia thrombocytopenia

Depakote interacts with drugs that are Depakote interacts with drugs that are metabolized by the livermetabolized by the liver

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Contraindications for Contraindications for AnticonvulsantsAnticonvulsants

Hepatic or renal diseaseHepatic or renal disease

PregnancyPregnancy

LactationLactation

Presence of blood dyscrasiasPresence of blood dyscrasias

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Psychoeducation when using Psychoeducation when using anticonvulsantsanticonvulsants

Monitor blood levels of mood stabilizers to prevent Monitor blood levels of mood stabilizers to prevent toxicitytoxicity

Monitor liver, renal function tests and CBCsMonitor liver, renal function tests and CBCs

Depakote must be swallowed whole, not cut, Depakote must be swallowed whole, not cut, chewed, or crushed to prevent irritationchewed, or crushed to prevent irritation

Evolution of Antidepressant DrugsEvolution of Antidepressant Drugs

Phenelzine

Isocarboxazid

Tranylcypromine

Imipramine

Clomipramine

Nortriptyline

Amitriptyline

Desipramine

Fluoxetine

Sertraline

Paroxetine

Fluvoxamine

CitalopramBupropion

Nefazodone

MirtazapineReboxetine

Maprotiline

Amoxapine

1950 1960 1970 1980 1990

Phenelzine

Isocarboxazide

Tranylcypromine

Imipramine

Clomipramine

Nortriptyline

Amitriptyline

Desipramine

Fluoxetine

Sertraline

Venlafaxine

Maprotiline

AmoxapineEscitalopramDuloxetine

2000

MianserineTrazodone

Moclobemide

TianeptineMilnacipran

2009

Valdoxan

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AntidepressantsAntidepressants

Treatment of depressive moods, including Treatment of depressive moods, including bipolar disease bipolar disease

4 categories:4 categories:– Tricyclics (TCA)Tricyclics (TCA)– MAOI’sMAOI’s– SSRI’SSSRI’S– Atypical AntidepressantsAtypical Antidepressants

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Antidepressant DrugsAntidepressant Drugs

TricyclicsTricyclics- Elavil, Tofranil- Elavil, Tofranil

SSRI’sSSRI’s- Lustral, Seroxat - Lustral, Seroxat

MAOI’sMAOI’s- Nardil, Parnate- Nardil, Parnate

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Atypical AntidepressantsAtypical Antidepressants

Inhibits reuptake of Inhibits reuptake of serotoninserotonin::

Trazodone (desyrel)Trazodone (desyrel)

Norepinephrine Dopamine Norepinephrine Dopamine Reuptake Inhibitor (NDRI)Reuptake Inhibitor (NDRI): : Wellbutrin (Bupropion)Wellbutrin (Bupropion)

Sertonin Norepinephrine Sertonin Norepinephrine Reuptake InhibitorReuptake Inhibitor-(SNRI): -(SNRI): Effexor (venlafaxine)Effexor (venlafaxine)

Cymbalta (duloxetine)Cymbalta (duloxetine)

Increases release of Increases release of serotonin & norepinephrine: serotonin & norepinephrine: Remeron (mirtazapine)Remeron (mirtazapine)

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Atypical AntidepressantsAtypical Antidepressants

Trazodone:Trazodone:alternative to TCA’s, may cause orthostatic hypotension, alternative to TCA’s, may cause orthostatic hypotension, sedation, and priapism in malessedation, and priapism in males

Remeron:Remeron: causes sedation, weight gain, dry mouth, constipationcauses sedation, weight gain, dry mouth, constipation

Wellbutrin Wellbutrin (zyban): rarely causes sedation, weight Gain, (zyban): rarely causes sedation, weight Gain, or sexual dysfunctionor sexual dysfunction– Used for smoking cessation. Most common S/E are headaches, Used for smoking cessation. Most common S/E are headaches,

insomnia & nauseainsomnia & nausea– May lower seizure thresholdMay lower seizure threshold

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Atypical Antidepressants:Atypical Antidepressants: serotonin norepinephrine reuptake serotonin norepinephrine reuptake

inhibitor (SNRI)inhibitor (SNRI)

SNRI-blocks uptake of SNRI-blocks uptake of serotonin and norepinephrineserotonin and norepinephrine

Drugs include Drugs include EffexorEffexor & & CymbaltaCymbalta

Good for clients with anxiety Good for clients with anxiety

S/E:GI, sexual dysfunction, S/E:GI, sexual dysfunction, insomnia, agitationinsomnia, agitation

Skipping 1 dose can Skipping 1 dose can cause withdrawal S/Scause withdrawal S/S

Very effective in Very effective in treating severe treating severe depressiondepression

Cymbalta is effective in Cymbalta is effective in treating somatic treating somatic symptoms e.g. painsymptoms e.g. pain

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Major Indications for Major Indications for AntidepressantsAntidepressants

Major Depressive Major Depressive disorderdisorder

Bipolar depressionBipolar depression Anxiety disorders:Anxiety disorders:

Panic disorderPanic disorder Obsessive-CompulsiveObsessive-Compulsive Phobic disordersPhobic disorders

PTSDPTSD

Substance AbuseSubstance Abuse Chronic PainChronic Pain Tourette’s DisorderTourette’s Disorder ADHDADHD Eating disordersEating disorders Sleep disordersSleep disorders MigrainesMigraines EnuresisEnuresis

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TriCyclicAntidepressant (TCA): TriCyclicAntidepressant (TCA): Tryptizol, Pamelor, Tofranil, Anafranil, Tryptizol, Pamelor, Tofranil, Anafranil,

Aventyl, Asendin, SinequanAventyl, Asendin, Sinequan

Blocks the reuptake of Blocks the reuptake of norepinephrine and norepinephrine and serotoninserotonin

Tricyclic drugs block the Tricyclic drugs block the muscarine receptors muscarine receptors causing anticholinergic causing anticholinergic side effectsside effects

Other side effects:Other side effects:– Orthostatic Orthostatic

hypotensionhypotension– SedationSedation– Weight gainWeight gain– Confusion-esp. elderlyConfusion-esp. elderly– ArrhythmiasArrhythmias

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TCA’s ContraindicationsTCA’s Contraindications Do not mix with ETOH Do not mix with ETOH

(none of the psych drugs (none of the psych drugs should be mixed with should be mixed with ETOH)ETOH)

DementiaDementia Suicidal clientsSuicidal clients Cardiac diseaseCardiac disease PregnancyPregnancy Seizure disordersSeizure disorders Urinary retentionUrinary retention

Dose for elderly should Dose for elderly should be ½ of adult dosebe ½ of adult dose

TCA’s and MAOIs are TCA’s and MAOIs are effective in treatment of effective in treatment of depressiondepression– are not as safe nor are not as safe nor

well tolerated as the well tolerated as the newer antidepressantsnewer antidepressants

Toxic Effects:Toxic Effects:possibility of cardiac possibility of cardiac toxicity in toxicity in overdoseoverdose

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SSRI’sSSRI’s Prozac, Lustral, Seroxat, Faverin, Cipralex, SerzoneProzac, Lustral, Seroxat, Faverin, Cipralex, Serzone

Blocks the reuptake of serotonin into the neuronBlocks the reuptake of serotonin into the neuron

Are very safe and are not lethal in overdoseAre very safe and are not lethal in overdose

Good choice with the elderly-very few side effectsGood choice with the elderly-very few side effects

If used with MAOI’s may cause Serotonin Syndrome: seizure, deathIf used with MAOI’s may cause Serotonin Syndrome: seizure, death

If used with TCA’s may cause TCA toxicityIf used with TCA’s may cause TCA toxicity

Takes 2 weeks to feel effectsTakes 2 weeks to feel effects

Side-effect:Side-effect: GI, CNS however the biggest is sexual dysfunction & weight GI, CNS however the biggest is sexual dysfunction & weight gain gain

Contraindication: Cardiac dysrhythmiasContraindication: Cardiac dysrhythmias

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MAOI’sMAOI’s Nardil, ParnateNardil, Parnate

Inhibits MAO, thus interfering with breakdown of Inhibits MAO, thus interfering with breakdown of norepinephrine, dopamine, and serotoninnorepinephrine, dopamine, and serotonin

Avoid foods with tyramine (aged cheese, red wine, Avoid foods with tyramine (aged cheese, red wine, beer, chocolate, etc.) beer, chocolate, etc.)

MAOI’s don’t play well with other drugs!!MAOI’s don’t play well with other drugs!! Toxic effects:Toxic effects: hypertensive criseshypertensive crises

Adverse effets linked with Adverse effets linked with neurotransmitter neurotransmitter

activity and receptor bindingactivity and receptor binding

Adapted from Richelson 1993

Activating sideeffects

5-HT5-HT2 2

agonismagonism

Weight gain

Ach Ach antagonismantagonism

Blurred visionNausea5-HT5-HT3 3

agonismagonism

Activating effects

NE reuptakeNE reuptakeinhibitioninhibition

Postural hypotensionDizziness

Reflex tachycardia

αα2 2 antagonismantagonism

Priapism

DA reuptakeDA reuptakeinhibitioninhibition

Psychomotor activation

TraditionalAntidepressants

5-HT5-HTreuptakereuptakeinhibitioninhibition

H1H1

antagonismantagonism

αα1 1 antagonismantagonism

Dry mouth

Urinary retention

Activating effectsTremor-CV troubles

Sexual dysfunction

GI disturbances

Sedation/drowsiness

Dry mouth

Constipation

Sinus tachyardia

Urinary retention

Memory dysfunction

Psychosis - Abuse

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Antianxiety/Anxiolytic DrugsAntianxiety/Anxiolytic Drugs

GABA exerts an inhibitory effect on neuronsGABA exerts an inhibitory effect on neurons

These drugs enhance its effect and produce a These drugs enhance its effect and produce a sedative effectsedative effect

Therefore reduce anxietyTherefore reduce anxiety

The most common used drugs here are the The most common used drugs here are the BenzodiazepinesBenzodiazepines

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BenzodiazepinesBenzodiazepines Valium, Xanax, Ativan , Valium, Xanax, Ativan ,

Librium, LexotanilLibrium, Lexotanil

Dalmane, Halcion (used as Dalmane, Halcion (used as sleep aides-short term) sleep aides-short term)

Used for anxiety disorders, Used for anxiety disorders, ETOH withdrawal, muscle ETOH withdrawal, muscle spasm, sedation, insomnia, spasm, sedation, insomnia, and epileptics/seizuresand epileptics/seizures

Risk of dependency Risk of dependency

Avoid ETOHAvoid ETOH

Causes sedation-Causes sedation-don’t drive!!don’t drive!!

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BenzodiazepinesBenzodiazepines Side EffectsSide Effects

– Drowsiness, confusion, sedation, and lethargyDrowsiness, confusion, sedation, and lethargy

Toxic EffectsToxic Effects– Respiratory depression esp. with ETOH use!Respiratory depression esp. with ETOH use!

ContraindicationsContraindications– Combination with other CNS depressantsCombination with other CNS depressants– Renal or hepatic dysfunction (may use Ativan)Renal or hepatic dysfunction (may use Ativan)– History of drug abuse or addictionHistory of drug abuse or addiction– Depression and suicidal tendenciesDepression and suicidal tendencies

TeachingTeaching– Use short term due to risk of drug dependencyUse short term due to risk of drug dependency– Avoid ETOH and other CNS depressantsAvoid ETOH and other CNS depressants– Can impair ability to driveCan impair ability to drive– Sudden D/C of benzodiazepines might cause withdrawal s/sSudden D/C of benzodiazepines might cause withdrawal s/s

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Non-benzodiazepine AnxiolyticNon-benzodiazepine Anxiolytic BuSpar (Buspirone)BuSpar (Buspirone) Reduces anxiety without strong sedative-hypnotic propertiesReduces anxiety without strong sedative-hypnotic properties Not a CNS depressantNot a CNS depressant Takes 2 weeks to feel effects Takes 2 weeks to feel effects No potential for addictionNo potential for addiction Side EffectsSide Effects

– Dizziness, dry mouth, nervousness, diarrhea, headache, excitementDizziness, dry mouth, nervousness, diarrhea, headache, excitement

Toxic EffectsToxic Effects– Lethal dose is 160-550 times the daily recommended doseLethal dose is 160-550 times the daily recommended dose

ContraindicationsContraindications– Use with caution in PG womenUse with caution in PG women– Nursing mothersNursing mothers– Clients with renal or hepatic diseaseClients with renal or hepatic disease– Anyone taking MAOsAnyone taking MAOs

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Sedative/Hypnotic DrugsSedative/Hypnotic Drugs Anxiolytic and hypnoticAnxiolytic and hypnotic

Can lead to tolerance and dependencyCan lead to tolerance and dependency

Use for short termUse for short term

Drugs usedDrugs used

benzodiazepines:benzodiazepines: Dalmane, Restoril, Halcion Dalmane, Restoril, Halcion

Non-benzodiazepines:Non-benzodiazepines: Ambien, Sonata, Lunestra Ambien, Sonata, Lunestra

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Psychoeducation when using Psychoeducation when using Benzodiazepine TeachingBenzodiazepine Teaching

Use short term(1-2 weeks)Use short term(1-2 weeks)

Carefully need to taper these off-never stop cold turkeyCarefully need to taper these off-never stop cold turkey

Do not take with other meds without talking to provider Do not take with other meds without talking to provider firstfirst

Do not drive if sedated on these!!Do not drive if sedated on these!!

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Client Teaching forClient Teaching for Non-benzodiazepines Non-benzodiazepines

Long term use not recommendedLong term use not recommended

Do not drive when takingDo not drive when taking

Can repeat Sonata up to 4 hours before arisingCan repeat Sonata up to 4 hours before arising

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ADD/ADHD-PsychostimulantsADD/ADHD-Psychostimulants

Ritalin, Adderall, Ritalin, Adderall, Dexedrine, Concerta,Dexedrine, Concerta,

DaytranaDaytrana

Action=Action=

increasing the release increasing the release and blocking the and blocking the reuptake of reuptake of monoamines monoamines (dopamine, (dopamine, norepinephrine)norepinephrine)

S/E:S/E: wt. loss, anorexia, wt. loss, anorexia, insomnia, headache, long-insomnia, headache, long-term growth suppressionterm growth suppression

Potential for abusePotential for abuse

Also used to treat Also used to treat narcolepsynarcolepsy

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ADD/ADHD-PsychostimulantsADD/ADHD-Psychostimulants

Intended effects:Intended effects:– Increased attention span & concentrationIncreased attention span & concentration– Decreased distractibility, hyperactivity, and impulsivityDecreased distractibility, hyperactivity, and impulsivity– Treatment of ADHD, ADD, & narcolepsyTreatment of ADHD, ADD, & narcolepsy

S/E:S/E:– AnorexiaAnorexia– Wt. lossWt. loss– Growth retardation in childrenGrowth retardation in children– InsomniaInsomnia– HeadacheHeadache– Cardiovascular effects-high blood pressure, dysrhythmiasCardiovascular effects-high blood pressure, dysrhythmias

Contraindications:Contraindications:– Hx of drug abuse & dependency, severe anxiety, anorexia, Hx of drug abuse & dependency, severe anxiety, anorexia,

MAIOIsMAIOIs

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ADD/ADHD- Non-StimulantsADD/ADHD- Non-Stimulants StratteraStrattera (atomoxetine)(atomoxetine)

– Controls symptoms thru selective inhibition of Controls symptoms thru selective inhibition of norepinephrinenorepinephrine

– Takes 1-3 weeks to feel effectsTakes 1-3 weeks to feel effects

– No abuse potential and is not considered a No abuse potential and is not considered a controlled substancecontrolled substance

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Meds used to Treat Meds used to Treat Extrapyramidal SEExtrapyramidal SE

CogentinCogentin BenadrylBenadryl ArtaneArtane SymmetrelSymmetrel RequipRequip AkinetonAkineton KemadrinKemadrin

These meds should be These meds should be taken simultaneously taken simultaneously with antipsychotic with antipsychotic meds to prevent EPSmeds to prevent EPS

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Herbal MedicinesHerbal Medicines Ginkgo biloba-helps with memoryGinkgo biloba-helps with memory Kava-KavaKava-Kava St. John’s WartSt. John’s Wart

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Questions after lecture?Questions after lecture?

Please e-mail (kbazaid@ksu.edu.sa) or call Please e-mail (kbazaid@ksu.edu.sa) or call (01 467 1717)(01 467 1717)

Interested in learning more about child and Interested in learning more about child and adolescent psychiatry?adolescent psychiatry?– Arrange to attend OPD Arrange to attend OPD – Consider an elective rotation during internship Consider an elective rotation during internship

or otherwiseor otherwise

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Meds for Alzheimer’sMeds for Alzheimer’s

Drugs here are used to Drugs here are used to slow the progression slow the progression of the diseaseof the disease

MemantineMemantine (Namenda, Ebixa)(Namenda, Ebixa)

Cognex Cognex (tacrine)(tacrine) Aricept Aricept (donepezil)(donepezil) Exelon Exelon (Rivastigmine) (Rivastigmine) RazadyneRazadyne

(galantamine)(galantamine)

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PET ScanPET Scan=positron-emission =positron-emission tomography (PET) scanstomography (PET) scans

Useful in identifying physiological and biochemical Useful in identifying physiological and biochemical changes as they occur in living tissue changes as they occur in living tissue – i.e. clients with i.e. clients with schizophreniaschizophrenia PET scans show a PET scans show a

decrease of glucose in the frontal lobes of unmedicated decrease of glucose in the frontal lobes of unmedicated clients, also can indicate clients, also can indicate mood disordersmood disorders, , ADHD ADHD

Radioactive substance is injected, travels to the Radioactive substance is injected, travels to the brain, and illuminates the brain. Have 3D brain, and illuminates the brain. Have 3D visualizations of the CNSvisualizations of the CNS